CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1167 5174.500000 191456.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1167 5174.500000 191456.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 14.000000 1050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 30.000000 1665.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 92 77.500000 5812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 124 99.500000 7462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 254 252.500000 14013.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 94 78.500000 5887.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 1119.2900 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 6 6.000000 499.7400 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 210.7800 23.4200
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
Subtotal (Total Children Is Unduplicated) 304 613.500000 39745.0500 64.7841
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Total 5788.000000 231201.5500 39.9450
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Number of Children (Unduplicated) With at Least One Service 1176
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Center 04
Flag Claims Units Chgs Paid
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R 8 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1102 1621.250000 62689.0000 0.0000
P 2446 3897.750000 153367.6500 153478.8900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
286 260.500000 14830.4000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3842 5788.000000 231201.5500 153478.8900